=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255738829
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIO VASCULAR PLUS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2014
-----------------------------------------------------
Last Update Date | 12/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7891 MISSION GROVE PKWY S SUITE C
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92508-5056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-347-9731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7891 MISSION GROVE PKWY S SUITE C
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92508-5056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-347-9731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | EDWIN LOUIS DAGOSTINO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 951-789-4356
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 53579
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------